[Therapeutic challenges in difficult-to-treat, penetrating Crohn's disease - a multidisciplinary approach]

Rectovaginal fistula is a rare complication of penetrating Crohn’s disease, and if present, a combined use of pharmacological treatment and surgical intervention is recommended. Although high efficacy has been demonstrated with TNFα blockers in Crohn’s disease complicated by perianal fistulas, it has been less evident in rectovaginal fistulas, presumably for anatomical factors and due to reduced ability to penetrate the tissue at the site of inflammation. Data on the effectiveness and safety of newer biologics and small molecule agents in penetrating Crohn’s disease are limited. We report the case of a young woman with penetrating Crohn’s disease who received multiple lines of biological treatment for moderate-to-severe disease activity and recurrent rectovaginal fistula. As ultimum refugium, deviating ileostomy formation was carried out and upadacitinib was started as the fifth line of therapy. After a 12-week induction period, closure of the rectovaginal fistula as well as complete mucosal healing of the entire colon was detected. The selective JAK1-inhibitor upadacitinib has been shown to be effective in difficult-to-treat, penetrating Crohn’s disease with moderate-to-severe luminal activity and recurrent rectovaginal fistula. Orv Hetil. 2024; 165(32): 1252–1257.